Take the “Certification of Health Care Provider ” form to the physician of the patient that the leave is being requested for. Have the physician complete the form. For a family member, be sure to sign and date the form in the employee section.

Write a letter to Human Resources stating why you are requesting the leave. The letter must include the name of the employee, name and relationship of the patient, medical condition of the patient, and the intentions of the leave (duration).

Submit the completed “Certification of Health Care Provider ” form and the letter to Human Resources for review.

Upon receipt, Human Resources will determine if the request falls within the guidelines of the Family and Medical Leave Acts (Wisconsin and/or Federal). You will receive a letter stating whether the leave has been approved or not, complete with rationale.

An employee must apply for the Family and Medical Leave Act within a timely manner of the onset of the medical condition. If there are any questions regarding these procedures, please feel free to contact Human Resources at 459-3553 or 459-6460.